live united - Orange County United Way

... damage (including any injury or property damage caused by negligence) associated with my participation ... I agree to permit photographs, video or digital tapes, movies and/or sound recordings of myself (or my child) for the ... Signature: ...
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LIVE UNITED Orange County United Way

Name: ______________________________________________________________________________________________ Home Address: ______________________________________________________________________________________ Home email: ____________________________________

Home Phone: ________________________________

Company: ___________________________________________________________________________________________ Address: ____________________________________________________________________________________________ Work email: ______________________________________

Work Phone: __________________________________

Emergency Contact: ______________________________

Phone: _____________________________________

United Way, a not-for-profit organization, may enter your name and some information about the event and/or activity in which you participate into a database, to help us evaluate the impact of our work. Your personal information will never be shared. If you do not want your name included, please speak with a United Way staff member. LIABILI TY. I hereby release, indemnify and hold harmless United Way, the organizers, sponsors, agency partners, and supervisors of all its activities, from any and all liability in connection with any injury and/or property damage (including any injury or property damage caused by negligence) associated with my participation in all events including volunteer events and other activities. I will not participate unless I complete this form in its entirety. This agreement will remain in force unless I notify United Way in writing. PHOTO AUTHORIZATION & RELEASE. I agree to permit photographs, video or digital tapes, movies and/or sound recordings of myself (or my child) for the purpose of television, radio, newspaper or outdoor advertising, billboards, bus covers, videos, printed materials, internet and/or news stories. I (or my child) will not receive payment for these pictures and will have no right to view or approve them before or after they have been used. I understand that there is no time limit to this agreement. I hereby authorize and consent that United Way, its legal representatives, successors or assigns, shall have the absolute right to copyright, publish, use, sell or assign any and all photographic portraits or pictures, television spots, movie films, videotapes and/or sound recordings, or any part thereof, they have taken or made of me from this date forward or in which I may be included in whole or in part, whether apart from or in connection with, illustrative or written printed matter, story or news item, motion pictures, television or radio spots, or publications appearing on the internet or world wide web, or for publicity, advertising or any other lawful purpose whatsoever, in conjunction with my own or a fictitious name, or in reproductions thereof in color or otherwise. I hereby waive all claims for any compensation for such use or for damages, now or anytime in the future. I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied, now or anytime in the future. I hereby warrant that I am of full age and have every right to contract in my own name in the above regard. Or, if the subject of said contract is a minor, I hereby consent and agree, individually, and as a parent or legal guardian of said minor, to all the terms and provisions stated above. I state further that I have read the above authorization and release, prior to its execution, and that I am fully familiar with the contents thereof.

Signature: _______________________________________________ Date: _______________________________ If you are responsible for minors under 18 years of age, please list their names below:

Minor Name: ___________________________________________________________________________________ Minor Name: ________________________________